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Registration Form 2013-2014

One Time Registration Fee: $15.00.  *Additional forms may be required for specific programs*

Member Information
Parent/Guardian Information
Primary Parent/Guardian
Secondary Parent/Guardian
Emergency Contacts & Authorized Pick-Ups
(In Case of Emergency, Parents/Guardians are always contacted first)
First Emergency Contact
Second Emergency Contact
Third Emergency Contact
The following information issued for grant purposes only.
It will not be shared.
Medical Permission Form
By electronically signing this registration form, I give permission for my child to receive emergency treatment and to be hospitalized at my expense, if necessary.  I understand that every effort will be made to contact me before taking action.  I also agree to update Girls Inc. of Worcester if there are any changes in the following information.
Girls Incorporated Activity Permission
I give permission for my child to participate in Girls Incorporated Signature programs and to be transported by Girls Incorporated staff to and from these activities, field trips, and school centers.  I understand that my medical coverage is the primary insurer for my child and will not hold Girls Inc. responsible in case of an accident.  
2.  I give permission for images in print and electronic form and videos taken of my child during programs to be used for public relations purposes in newsletters, brochures, annual reports and for publicity on our website, radio, television, and newspapers.  
3.  I am aware there is a late fee of $15.00 for each 15 minutes that I am late to pick up my child.

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